2011-02-15T17:36:23-06:00 2010-06-30 SEIM JOHNSON SESTAK & QUIST LLP 8807 INDIAN HILLS DRIVE SUITE 300 OMAHA NE 681144123 990 2009-07-01 420859940 BURGESS HEALTH CENTER BURG 7124232311 1600 DIAMOND STREET ONAWA IA 51040 FRANCIS TRAMP 7124232311 2011-02-09 1 4023302660 2009 2016-02-24 21:20:13Z FRANCIS TRAMP 1600 DIAMOND STREET ONAWA IA 51040 25586731 0 X www.burgesshc.org X 1959 IA TO PROVIDE HEALTHCARE SERVICES TO THE COMMUNITY 11 11 287 87 2726421 -240673 133557 157780 22830620 24053101 -38970 151917 68290 72316 22993497 24435114 0 0 9658061 10532447 0 0 11414758 12504750 21072819 23037197 1920678 1397917 28581416 30161690 9829373 10183746 18752043 19977944 Burgess Health Center is committed to improve the quality of life for the people and communities it serves by providing excellent helthcare and exceptional patient experiences. 0 0 15918803 21326680 PROVIDES HEALTHCARE SERVICES TO COMMUNITY. 2662348 2726421 OPERATING A RETAIL PHARMACY IN TOWNS THAT WOULD NOT OTHERWISE HAVE THESE HEALTH SERVICES. 18581151 1 1 0 0 0 0 0 0 0 1 0 1 0 0 0 0 0 0 0 0 1 0 0 1 1 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 1 1 0 0 1 78 0 1 287 1 1 1 0 0 0 0 0 0 0 0 11 11 0 0 0 0 1 0 1 1 1 0 0 1 1 1 1 1 1 1 0 0 IA X shawn gosch cfo 7124239213 1600 DIAMOND STREET ONAWA IA 51040 Jim Westergaard 1.00 X X 0 0 0 Terry Framke 1.00 X X 0 0 0 Steve Pratt 1.00 X X 0 0 0 Paul Dudley MD 1.00 X 0 0 0 Mary Black 1.00 X 0 0 0 John Garred Jr MD 1.00 X 0 0 0 Neal Gorham 1.00 X 0 0 0 Mari Miller 1.00 X 0 0 0 Todd Sadler 1.00 X 0 0 0 Charles Sederstrom 1.00 X 0 0 0 Jim Stangel 1.00 X 0 0 0 Francis Tramp 40.00 X 140558 0 13133 Shawn Gosch 40.00 X 92674 0 12204 Kim Norby 40.00 X 94315 0 1988 Monty McKinven 40.00 X 236494 0 15043 Peter Daher MD 40.00 X 279226 0 10229 Richard Hutchson 40.00 X 190577 0 4141 Scott North 40.00 X 111924 0 12560 Jane Judt 40.00 X 104756 0 12408 1250524 0 81706 6 0 1 0 CPSI PO Box 850309 Mobile AL 366850309 Computer Services 231269 mckesson information solutions one post street san francisco CA 94104 computer support 206430 ST LUKES DEPARTMENT OF LAB SERVICES 2720 stone park blvd SIOUX CITY IA 51104 LAB SERVICES 191967 Waseem Alounk MD 3003 north 170th street omaha NE 68116 ER physician 129625 4 13441 68687 75652 157780 medicare/medicaid paym 624100 11218095 11218095 PATIENT REVENUE 624100 9823140 9823140 RETAIL PHARMACY 446110 2726421 2726421 MENTAL HEALTH APPR 624100 70004 70004 physical therapy servi 624100 53282 53282 162159 162159 24053101 130729 130729 117672 45356 72316 72316 72316 1101569 25880 1099517 6744 2052 19136 21188 21188 24435114 21326680 2726421 224233 606409 251537 354872 8177641 6806456 1371185 116169 97012 19157 1029209 892080 137129 603019 517605 85414 47699 47699 46410 46410 1741720 1326302 415418 44137 38237 5900 4019773 3501472 518301 293370 179019 114351 147280 110451 36829 375036 375036 1564702 728150 836552 104077 104077 RETAIL PHARMACY EXPENSE 2662348 2662348 BAD DEBT EXPENSE 1246961 1246961 DUES AND SUBSCRIPTIONS 90407 27595 62812 MISCELLANEOUS EXPENSES 65489 37667 27822 LICENSES AND TAXES 55341 54182 1159 23037197 18581151 4456046 0 3316915 3138901 3489056 2421838 3226701 3978089 19655 9827 94382 77325 873862 873502 180560 255788 25050530 10084047 15347526 14966483 1820062 4030896 9178 212697 399863 28581416 30161690 1411275 1828005 7900000 7545000 518098 810741 9829373 10183746 X 18752043 19977944 18752043 19977944 28581416 30161690 X 0 1 1 X 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 49842 49842 17562831 5497233 12065598 6902359 4232665 2669694 535498 354149 181349 14966483 ESTIMATED THIRD PARTY PAYABLES 810741 810741 24435114 23037197 1397917 -172016 -172016 1225901 24263098 -172016 -172016 24435114 0 24435114 23037197 0 23037197 0 23037197 Part X: Description of Uncertain Tax Positions Under FIN 48: the health center and foundation are not-for-profit corporations as described in section 501(c)(3) of the internal revenue code and are exempt from federal income taxes on related income pursuant to section 501(a) of the code. the internal revenue service has established standards to be met to maintain the health center and foundation's tax exempt status. in general, such standards require the health center and foundation to meet a community benefits standard and comply with various laws and regulations. 1 1 1 X 1 X 245.000000000000 1 1 1 0 1 0 230 336588 0 336588 0.01540 2878 1524352 1096644 427708 0.01960 3108 1860940 1096644 764296 0.03500 11 2964 16071 19605 -3534 0.00000 4 5552 1253936 917201 336735 0.01550 1 1435 24710 3663 21047 0.00100 16 9951 1294717 940469 354248 0.01650 16 13059 3155657 2037113 1118544 0.05150 0 720192 336588 4564513 10010536 -5446023 X 1 1 BURGESS HEALTH CENTER

1600 DIAMOND STREET ONAWA IA 61040

X X X X burgess family clnic - sloan

409 evans sloan IA 51055

family medical clinic burgess family clnic - dunlap

612 Iowa Avenue dunlap IA 51529

family medical clinic burgess family clnic - decatur

12th Broadway decatur NE 68020

family medical clinic burgess family clnic - maple VALLEY

111 s 5th street mapleton IA 51304

family medical clinic Part I, Line 3c: Eligibility for discounted and free care to low income individuals is based on financial assistance sliding-fee schedule utilizing a derivative of the current US Dept. of Housing and Urban Development (HUD) very low income guidelines. The Sliding-fee schedule is used as a guide to identify the amount of financial assistance granted using the applicant's financial application and applicable supporting documents. Part I, Line 6a: the report is prepared by burgess Health center. Part I, Line 7: BURGESS HEALTH CENTER USES LIONS SOFTWARE TO TRACK ALL PROGAMS THROUGHOUT THE YEAR. WHEN A PROGRAM IS USED, THE PERSON IN CHARGE WILL TRACK THE PROGRAM IN THE SOFTWARE BY RECORDING THE CATEGORY, THE RELATED COSTS AND REVENUE AND THE NUMBER OF PARTICIPANTS. Part I, Line 7g: ALL COSTS REPORTED ON PART I, LINE 7G ARE ATTRIBUTABLE TO THE PHYSICIAN CLINICS. Part I, Line 7f: BAD DEBT EXPENSES EXCLUDED FROM CALCULATING PART I, LINE 7, COLUMN (F) IS $1,250,333. Part III, Line 4: THERE IS NO FOOTNOTE RELATED TO BAD DEBT EXPENSE IN THE FINANCIAL STATEMENTS. TO CALCULATE BAD DEBT EXPENSE AT COST, BURGESS HEALTH CENTER MULTIPLIED THE BAD DEBT EXPENSE RECORDED ON THE BOOK BY A COST-TO-CHARGE RATIO CALCULATED FROM THE COST REPORT. TO DETERMINE THE AMOUNT ON PART III, LINE 3, BURGESS HEALTH CENTER FOLLOWS THEIR CHARITY CARE POLICY AND RECORDS CHARITY CARE AT COST. The rationale for including bad debts in community benefits is that over fifty percent of bad debt is attributed to patients who could apply for charity care but don't. furthermore, patients come to the Emergency rooM knowing they will not have to pay for the services performed. Part III, Line 8: BURGESS HEALTH CENTER DOES NOT FEEL THAT A MEDICARE SHORTFALL SHOULD BE LISTED AS A COMMUNITY BENEFIT AT THIS TIME. THE AMOUNT REPORTED ON PART III, LINE 6 WAS TAKEN FROM THE MEDICARE COST REPORT FOR THE YEAR ENDED JUNE 30, 2010. Part III, Line 9b: Burgess Health Center has a financial counselor who will review outstanding accounts with patients to help them qualIfy for assistance in paying the outstanding bill. This assistance includes completing paperwork and gathering source documents to determine if the patient qualifies for financial assistance. the Financial Counselor will also assist patients in completing paperwork in order for them to qualify for government assistance. Part VI, Line 2: Burgess Health Center reviews data from the Iowa department of Public Health. burgesS health center focuses on top admits to the hospital and reviews the aggregate date from wellness screens. Part VI, Line 3: Patients' bills contain information regarding the health center providing assistance if needed and gives contact information for this assistance. If a patient has not responded to the bill, the financial counselor will contact the patient to make arrangements to help the patient in receiving assistance. Part VI, Line 4: burgess health center is situated in Monona County, iA. the service area is considered rural setting with a population of approximately 15,000. Of this population, 30% is considered elderly which is one of the highest if not the highest % of elderly for any area in the state of iowa. The service area ranks low regarding the median household income. The Iowa median household income for 2009 was $47,324 with Monona County having a median household income of $38,362 - nearly $9,000 lower. Part VI, Line 5: burgess health center did not report any community building activitIes in part ii of schedule h. Part VI, Line 6: Promoting the health of the communities burgess health center serves is important to the health center. FuRthermore, it is part of the mission statement of burgess health center. - "Burgess Health Center is committed to improve the qualIty of life for the people and communities we serve by providing excellent healthcare and exceptional patient experiences."Burgess Health Center partners with other organizations in the community to improve community health and well being. burgess health center participates in MedIcare, Medicaid Champus and Tricare. Part VI, Line 7: burgess health center is not part of an affiliated health care system. IA X X X 0 0 0 0 0 0 0 0 0 Francis Tramp 140558 0 0 0 0 0 2904 0 10229 0 153691 0 0 0 Monty McKinven 236494 0 0 0 0 0 4814 0 10229 0 251537 0 0 0 Peter Daher MD 264226 0 15000 0 0 0 5666 0 4563 0 289455 0 0 0 Richard Hutchson 190577 0 0 0 0 0 3902 0 239 0 194718 0 0 0 City of Onawa Iowa Hospital Revenue Bonds Series 2005 426005064 682293AV7 2005-06-08 9200000 BUILDING PROJECT 0 0 9413218 734045 184000 8495173 2007 0 0 1 1 0 0 0 0 1 0.00000 0.00000 0.00000 1 0 0 0 0 1 1 FRANCIS TRAMP TUITION X 29457 9827 0 1 1 9827 Form 990, Part VI, Section A, line 6 burgess health center has members. a person may become a member if he or she is at that time a resident of the geographic area served by the corporation and then only upon completion of a membership registration form and payment of a life membership of $10. Form 990, Part VI, Section A, line 7b there is an annual meeting of the members. at the annual meeting, the members receive an annual report on the affairs of the corporation and have the opportunity to offer their input on any matter affecting the corporation. the members shall also carry out any duties reserved to members under the Iowa Nonprofit Corporation Act. Each member has one vote. the act of a majority of members present and voting shall be the act of the members. Form 990, Part VI, Section B, line 11 The Form 990 and the Related Schedules are presented to the Finance Committee by Shawn Gosch, CFO, at the first scheduled finance committee meeting after the completion of the form 990. with the extension, the form 990 is due february 15, 2011 and will be reviewed prior to submission. Form 990, Part VI, Section B, line 12c On a annual basis, all board members along with the management staff (managers, directors, officers) complete a confilct of intrest questionnaire. The results are reviewed at one of the Board meetings. Form 990, Part VI, Section B, line 15a The CEO salary is determined based on Grade, Number of years in the position and compared to IHA (Iowa Hospital Assoc.) data showing market rates for the Burgess Custom Group. This information is passed on to the Executive Committee of the Board who makes A RECOMMENDATION TO THE COMPLETE BOARD OF DIRECTORS. THE BOARD OF DIRECTORS IS RESPONSIBLE FOR the final decision. Form 990, Part VI, Section C, line 19 BURGESS HEALTH CENTER DOES NOT MAKE ITS GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, OR FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC. FORM 990, PART XI, LINE 2C: THE BOARD OF DIRECTORS ASSUMES THE RESPONSIBILITY FOR OVERSIGHT OF THE AUDIT OF ITS CONSOLIDATED FINANCIAL STATEMENTS AND SELECTION OF AN INDEPENDENT ACCOUNTANT. THIS PROCESS HAS NOT CHANGED FROM THE PRIOR YEAR. BURGESS FOUNDATION 1600 DIAMOND STREET ONAWA IA 51040 421188964 raising funds for burgess health center IA 501(c)(3) 11b N/A burgess health corp employee benefit turst 1600 DIAMOND STREET oNAWA IA 51040 421320408 provide health beenfits to employees of burgess health center IA 501(c)(9) n/a N/A 0 0 1 0 0 0 0 0 0 0 0 0 1 1 0 1 1 1 BURGESS FOUNDATION C 13441 burgess health corp employee benefit trust Q 913927